Reflections on Mortality

The 2018 Festival is proving to be as spectacular as ever – so much talent, such variety. You’d need to be a complete Philistine not to find something to your taste and I’m having a ball. And there’s so much to soak up around and about the city besides the featured events. During a visit to Blackwell’s book shop for their Writers at the Fringe event, for example, I noticed a book display dedicated to the 70th anniversary of the NHS, several of the exhibits talking about the art as well as the science of caring, and as I sat waiting for the five authors to begin their presentations, it got me thinking.

Wouldn’t we all love to be cared for by a truly empathetic compassionate doctor in our last months, weeks, days? I found one recently – one moreover who recognises that ‘Doctors – like writers, artists, and spies – are professional people-watchers‘. Sounds like my kind of person, huh?

I’ve been intimately acquainted with death since the age of 18. To some extent health care professionals have to learn to maintain a safe distance in order to keep on giving, but it’s a difficult balance to achieve. I once worked with a lovely young doctor (who has been my friend for over forty years) who was so nervous when he had to convey bad news that he giggled. As his colleague I understood it was because he cared too much for his own comfort; the relatives couldn’t know that and were probably appalled by his seeming insensitivity.

Asian American doctor Pauline Chen learned through bitter experience too, and she’s taken the brave step of writing about the difficulties and pain of contemplating death and walking alongside people facing its reality in Final Exam: A Surgeon’s Reflections on Mortality. Like most naive youngsters she entered medicine with a rosy view of saving countless lives; she had no idea of the extent to which death would become such a haunting constant in her career. But in a society where more than 90% of patients will die from a prolonged illness, she joined the ranks of those whose task it is to shepherd the terminally ill and their families through the intricacies and pitfalls of the end, those who are expected to know how to provide comfort and support.

Initially Chen discovered from her mentors and teachers how to suspend or suppress shared human feelings, to adopt the twin coping mechanisms of denial and de-personalisation. At first, too raw to be let loose on patients, she learned to detach from the elderly lady cadaver in the dissection lab where the formaldehyde, used to preserve dead bodies pervaded her clothes and hands and hair – the olfactory version of a high-pitched shriek. Once out in the clinical arena, she had far more disturbing senses to deal with and she learned to avoid, obfuscate, reinvent, disguise, deny.

‘Even medical students chosen for their humanitarian qualities and selected from a huge pool of applicants may have their generous impulses profoundly suppressed by their medical education.’

But gradually, painfully, she came to realise, through a multiplicity of small inconsistencies and troubling paradoxes, that these techniques were in fact incapacitating her. She began to extricate herself from those same learned responses and to open herself up to something far more rewarding than curing someone. She came to see that when terminally ill patients were ‘Pushed to view their own mortality directly, they too would live the remainder of their own lives that much more fully than the rest of us.’ New dimensions, wider horizons, opened up to her: that, in fact, ‘… dealing with the dying allows us to nurture our best humanistic tendencies.’ And she came to appreciate the advice of a much respected colleague who was both oncologist and cancer patient: ‘You’ll be a better doctor if you can stand in your patients’ shoes.’ That the ‘honor of worrying – of caring, of easing suffering, of being present – may be our most important task, not only as friends but as physicians, too. And when we are finally capable of that, we will have become true healers.‘ I love the idea of it being an honour to worry and care.

Final Exam is a beautifully crafted book, from the simple but evocative cover and the so-apposite title page, through the quality paper, to the single tribute on the back from one of my favourite medical authors, Atul Gawande:‘..a revealing and heartfelt book. Pauline Chen takes us where few do – inside the feeling of practicing surgery, with its doubts, failures, and triumphs. Her tales are also uncommonly moving, most especially when contemplating death and our difficulties as doctors and patients in coming to grips with it.’

In telling the stories of many of her patients alongside her own, Pauline Chen has generously shared what it means to have the grace and humility to examine our own imperfections and misconceptions, to learn from the honesty, pain and sorrow of others, to become a more empathetic and warm human being. We don’t need to be practising health care professions to learn from her example.